Why the NFL Sucks at Concussion Testing, And What It Can Do About It

Detroit Lions wide receiver Calvin Johnson, moments after taking a hit that left him concussed during a game against the Minnesota Vikings on Sept, 30. Despite the injury, Johnson was back in the game less than 12 minutes later. Some neurologists say the NFL, despite its campaign against head trauma, lacks adequate tools to diagnose concussions from the sidelines. Photo: Rick Osentoski/Associated Press

The only thing more troubling than the hit that rattled Calvin Johnson’s brain was what happened when he finally got back up.

The Detroit Lions’ star receiver had leaped gracefully to catch a pass thrown by Matt Stafford, but the ball sailed just beyond his grasp. Johnson was still airborne when Chad Greenway of the arch-rival Minnesota Vikings hit him squarely in the face mask with the crown of his helmet. The league’s best receiver landed in a heap, writhing on the turf. Ford Field fell silent. Greenway backed away, hands on his head, visibly shaken.

Trainers rushed to Johnson’s aid. Minutes later, they led him from the field. Upon reaching the sideline, Johnson fell to his knees and clutched his head. If ever there was a defining image of the epidemic of concussions sweeping the NFL, Johnson embodied it.

What happened next shows the NFL — despite a lot of talk, a national television campaign hailing its devotion to improved safety and a $30 million donation to the National Institutes of Health to study brain trauma — still cannot claim to have a coherent, effective way of dealing with concussions, let alone adequate tools for diagnosing them on the field.

Just 11 minutes and 44 seconds after taking a hit that should have ended his game, Johnson returned to the field. It was the fourth quarter, after all, and the Lions were down 14 points to a division rival. There was no question he’d play. “It’s a part of football,” Johnson told Detroit’s WXYT-FM the following day. “You get concussed, you gotta keep on playing.”

Even more stunning, Johnson and his own coach can’t agree on what happened. Four days after the Sept. 30 matchup, Johnson announced he’d finished the game with a concussion. Not so, insists Lions head coach Jim Schwartz, who asserted at a press conference that Johnson “was thoroughly checked” on the sideline and cleared to resume playing.

Therein lies the problem. Johnson may well have been cleared to resume playing. Whether he was fit to resume playing is another question entirely, one that is notoriously difficult to answer on the sidelines because, several neurologists allege, the NFL lacks the tools needed to do so.

This problem comes as the NFL scrambles to address a crisis that’s been building since 2002, when Steelers center Mike Webster died of a heart attack at the age of 50. An autopsy revealed a brain mottled by a protein called tau, which typically is found in those with Alzheimer’s disease. But Webster didn’t have Alzheimer’s. He had a degenerative brain disease that has come to haunt professional football: chronic traumatic encephalopathy (CTE).

The neurological disease, found in athletes who have sustained repetitive head trauma, is marked by progressive degeneration of brain tissue. The buildup of tau can be identified only by autopsy, but early signs of CTE are appearing in athletes in their 20s. They include memory loss, confusion, impaired judgment, poor impulse control, aggression, depression, and eventually progressive dementia. A recent study by Boston University’s Center for the Study of Traumatic Encephalopathy, posthumously diagnosed the disease in 34 of 35 professional football players studied, including stars Dave Duerson, Cookie Gilchrist and John Mackey.

There is no doubt the league is concerned. In 2011, the NFL’s Head Neck and Spine Committee rolled out a league-wide concussion assessment protocol, and the league’s $30 million donation to the NIH for the study of mild traumatic brain injury is the largest in NFL history.

Yet for all the league’s efforts, Johnson’s story is hardly unique. During the tenth week of this season, three star quarterbacks – Alex Smith of the San Francisco 49ers, Jay Cutler of the Chicago Bears and Michael Vick of the Philadelphia Eagles – were concussed, and each remained on the field for several plays before being benched. Smith managed to throw a 14-yard touchdown pass despite having blurred vision after a brutal helmet-to-helmet hit.

The NFL doesn’t release statistics regarding concussions, but @NFLConcussions, a Twitter account tracking every publicly-disclosed concussion in the league, notes 194 players have left the field with head injuries through the 14th week of the season, an average of almost one concussion per game.

There is no doubt concussed players are getting top-notch care after they’re properly diagnosed. The problem is they aren’t always properly diagnosed.

“We are getting very good at managing concussions in an office setting, but we have a long way to go on the sideline,” says Dr. Michael Collins, director of the UPMC Sports Medicine program and an internationally renowned expert in sports concussions. “We can do better than what’s being done.”

What’s being done is, in many cases, is little more than a trainer holding up his hand and asking the player, “How many fingers do you see?”

“They come and do the little test with the finger, ask you what day, what game it is, stuff like that,” Johnson said of the sideline evaluation he received.

Trainers examine Chicago Bears quarterback Jay Cutler after he took a late hit from Houston Texans linebacker Tim Dobbins in the first half on Nov. 11. Cutler did not return in the second half after suffering a concussion. Photo: Nam Y. Huh/Associated Press

In most cases, team physicians use a test called the SCAT-2 – the Standardized Concussion Assessment Tool – to evaluate players after a big hit. It’s a nine-part physical and cognitive test conducted on the sidelines, and it takes 10 to 15 minutes. A physician recites a string of numbers or words and asks the player to repeat it. Players also answer simple questions, like who scored the last touchdown, and complete rudimentary coordination and balance tests similar to those cops give drunks – players close their eyes and touch their nose, for example, and to stand heel-to-toe with their eyes closed for 20 seconds.

A player is graded in each of nine areas and given a score out of 100. But there is no definitive “cut-off” score that determines whether a player should, or should not, return to the field. Rather, their score is compared to a baseline test, usually conducted during training camp. The sideline physician compares the two and makes a subjective decision based upon any perceived decline in the players performance.

Dr. Henry Feuer, a member of the NFL’s Head Neck and Spine Committee and a longtime team physician for the Indianapolis Colts, defends the test as an adequate tool. “The balance part of the exam is very hard to fool,” he says. “Players who have suffered a concussion are going to have a very difficult time closing their eyes and maintaining balance on one leg. We’re still not there in having a test that’s close to foolproof. But it’s much better than what was being done in the past.”

That may be, but the problem with SCAT-2 is balance is but one part of the overall score, and doesn’t make up for its other shortcomings, say neurologists Steven Galetta and Laura Balcer of the New York University Langone Medical Center. A key component of the SCAT-2 test, the Glasgow Coma Scale — which measures ocular, verbal and motor response, and represents 15 percent of the overall score — isn’t even applicable to sports concussions.

“The Glasgow Coma Scale was developed primarily as a way to measure severe to moderate head trauma,” like you might see in an automobile accident, Balcer says. “So players with concussions will often score very well on that part of the test. But even on the other parts of the SCAT-2 test, patients often have good scores despite having a concussion.”

For example, spontaneously opening your eyes nets a perfect 4-out-of-4 on the ocular portion of the test, he says.

Galetta believes the league must employ additional tests, and possibly a battery of them, on the sideline. He recommends the King-Devick test, which the NYU team has tested on MMA fighters and boxers with excellent results. It requires players to read aloud, as quickly as possible, a series of numbers, from left to right, printed on an index card. The test takes a healthy young person 40 seconds to complete. Concussed athletes have great difficulty processing the numbers and can take minutes to finish, if they don’t give up entirely, according to Galetta.

The advantage of the King-Devick is that it’s much more straightforward for an inexperienced physician or coach to grade than the SCAT-2, which relies on subjective analysis of symptoms and test results. Many concussed athletes in the team’s trials have passed the SCAT-2 exam but failed the King-Devick Test.

“The visual pathways account for about 55 percent of the brain’s pathways,” says Galetta. “Many of the structures for vision are coupled with the structures for cognition. There’s no real visual test on the SCAT-2. Memory and balance is just a part of the nervous system. It leaves a lot of territory untested.”

One reason the NFL relies solely on SCAT-2 is information overload. Researchers are rushing to validate a flood of new tools and tests for diagnosing and treating head trauma, but the league is under intense pressure to increase player safety right now. There’s simply too much data to consider, too many possibilities to explore without a better idea of what actually works.

“To be honest, these organizations are overwhelmed with expert opinion right now,” Galetta says. “They’re not necessarily in the business of validating these tests.”

Feuer, the NFL’s point man on concussions, concedes “we may still miss things,” but insists the league is light years ahead of where it was just a few years ago. He warns against making too much of the risk players face.

“In the not too distant past, if you had a concussion, you would be cleared in 15, 20 minutes and be back in the game,” he said. “50 percent of players used to go back in the game at all levels, from NCAA to the NFL. Did anything tragic happen? No.”

That may be a stretch, given that several high-profile players have committed suicide and later been found to suffer from CTE. But Feuer is right when he says it is far too simple, and unfair, to lay the blame on NFL trainers and physicians. The problem isn’t just the limitations of the sideline evaluation itself, but when and where it is administered. It is relatively easy to diagnose a concussion in an office setting one or two days after a big hit. Computerized neurological examinations like the ImPACT test, which Collins co-developed, can help physicians grade the severity of a concussion and predict recovery times.

‘Just because you’re a neurologist or a neurosurgeon or a primary care physician doesn’t mean that you have any idea about how to ask the right questions.’

But for all our advancements in identifying and managing concussions in the days after an injury, we’re still woefully ill-equipped to do so in the minutes and hours after an injury.

“The inherent problem with identifying concussions on the sideline is that not all the symptoms are evident immediately,” says Dr. Charles Tator, a brain surgeon at Toronto Western Hospital who treats many NHL players for concussions. “Often there is a latent period between the time of the hit and the time symptoms appear, which can be as long as several hours.”

So even if a player is willing to be honest about his symptoms and doesn’t fear losing his place on the squad (Smith was demoted from his starting role after being out with a concussion for one week), he may not even experience acute symptoms until long after the hit.

“What you see in the field might not be what you get 24, 48 hours later” Collins says.

This is an especially dangerous situation in youth leagues, where medical care often consists of a volunteer with little if any training and tools no more sophisticated than a SCAT-2 smartphone or iPad app. The Centers for Disease Control found concussion-related ER visits by those under 20 climbed 60 percent to 248,418 between 2001 and 2009.

“The training level in youth sports is not good, and it is such a critical problem because a child’s brain is much more susceptible to concussion than an adult brain,” Tator said. A recent study funded by the U.S. Department of Energy found that changes in the brain’s white matter can persist in children up to four months after the symptoms of a concussion have passed.

Perhaps more alarming, research shows youth players are taking hits almost as severe as college players. Researchers at Virginia Tech University, using accelerometers mounted to players’ helmets, recently found 7- and 8-year-old players occasionally absorbed forces as great as 80Gs, on par with those experienced by Virginia Tech players.

“The surprising thing is that the majority of the severe collisions were happening during practices,” says Steve Rowson, an assistant professor at Virginia Tech’s School of Biomedical Engineering and Sciences and one of the project’s researchers.

With this in mind, the Pop Warner Football Association is aggressively limiting exposure to head trauma. In June, the association – which includes more than 250,000 players – banned all head contact in practices, including blocking and tackling drills. Dr. Julian Bailes, director of the Brain Injury Research Institute, led the initiative.

“We believe that more than 60 percent of the concussions that occur in football happen during practice,” says Bailes, who was among the first to identify CTE in the brains of football players. “If you believe that the risk of sustaining a serious concussion is exposure based, which I do, then why don’t we eliminate the excessive exposure?”

Collins sees a different way forward. Instead of changing what happens between the sidelines, professional and youth sports should, with the medical community, focus on what’s happening beyond them.

“Educating clinicians would be my answer,” Collins says. “Just because you’re a neurologist or a neurosurgeon or a primary care physician doesn’t mean that you have any idea about how to ask the right questions, use the right tools, understand how to interpret them and implement an appropriate management plan for these kids.”

Educating the superstars who so inspire youth players would help, too. Despite the respect many NFL players say they have for traumatic brain injury in light of the suicides of players like Dave Duerson and Junior Seau, many still cannot acknowledge the elephant in the room. Even Johnson, so clearly rattled by the blow he took against the Vikings, said he isn’t concerned about the long-term effects of a concussion “Because I haven’t had a lot of them.”

That doesn’t matter, says Dr. Robert Cantu, clinical professor of neurosurgery at Boston University School of Medicine and a leading expert on CTE. There is a belief that a player had to suffer several concussions to be at risk of CTE, but there are documented cases of CTE resulting from a single instance of severe head trauma. More troubling still, Cantu says he has seen cases of CTE in athletes who took many sub-concussive blows, suggesting even a single blow to the head could be life-changing.

“If you’ve never seen it, I can understand why you might be skeptical,” Cantu says. “But I’ve seen it. It’s a fact.”

And yet despite all the commercials, donations and very serious talk coming from the NFL, if the Calvin Johnson fiasco is any indication, the NFL remains reluctant to embrace its own concussion education tagline, “when in doubt, sit them out.”